Harm Reduction Vs. Best interest of the client

1. Harm Reduction Vs. Best interest of the client By: Ashley Herman and Samantha Engelman

2. What is Harm Reduction? There are various definitions of harm reduction, a few might include: “Harm reduction is a public health strategy that was developed initially for adults with substance abuse problems whose abstinence was not feasible. Harm reduction approaches have been effective in reducing more morbidity and mortality in these adult populations” The International Harm Reduction Association (2002) describes harm reduction as: “Policies and programs which attempt primarily to reduce the adverse health, social and economic consequences of mood altering substances to individual drug users, their families and communities, without requiring decrease in drug use” “Harm reduction refers to policies, programs and practices that aim to reduce the harms associated with the use of psychoactive in people unable or unwilling to stop. The defining features are the focus on the prevention of harm, rather than on the prevention of drug use itself, and the focus on people who continue to use drugs” Harm reduction places emphasis on the social and economic outcomes and the overall measurement of health, versus the amount or measurement of ones drug abuse

3. Guiding Principles of Harm Reduction PRAGMATISM - Harm reduction recognizes that drug use is a complex and multi-faceted phenomenon that encompasses a continuum of behaviours from abstinence to chronic dependence and produces varying degrees of social harm. Harm reduction accepts that the non-medical use of psychoactive or mood altering substances is a universal phenomenon. It acknowledges that, while carrying risks, drug use also provides the user and society with benefits that must be taken into account. HUMAN RIGHTS - Harm reduction respects the basic human dignity and rights of people who use drugs. It accepts the drug user’s decision to use drug and no judgment is made either to condemn or support the use of drugs. Harm reduction acknowledges an individual drug user’s right to self-determination and supports informed decision making in the context of active drug use. Emphasis is placed on personal choice, responsibility and management. FOCUS ON HARMS - The fact or extent of an individual’s drug use is secondary to the harms from drug use. The priority is to decrease the negative consequences of drug use to the user and others, rather than decrease drug use itself. While harm reduction emphasizes a change to safer practices and patterns of drug use, it recognizes the need for strategies at all stages along the continuum of drug use. MAXIMIZE INTERVENTION OPTIONS - Harm reduction recognizes that people who use drugs benefit from a variety of different approaches. There is no one prevention or treatment approach that works reliably for everyone. It is providing options and prompt access to a broad range of interventions that helps keep people alive and safe. Individuals and communities affected by drug use need to be involved in the creation of effective harm reduction strategies. PRIORITY OF IMMEDIATE GOALS - Harm reduction starts with “where the person is” in their drug use, with the immediate focus on the most pressing needs. It establishes a hierarchy of achievable interventions that taken one at a time can lead to a fuller, healthier life for drug users and a safer, healthier community. Harm reduction is based on the importance of incremental gains that can be built on over time. DRUG USER INVOLVEMENT - Harm reduction acknowledges that people who use drugs are the best source for information about their own drug use, and need to be empowered to join the service providers to determine the best interventions to reduce harms from drug use. Harm reduction recognizes the competency of drug users to make choices and change their lives. The active participation of drug users is at the heart of harm reduction.

4. The Background on Harm Reduction Harm reduction has progressed and changed over time. In the 1960s and 1970s, activists, workers, programmes, doctors and policy-makers dedicated politically and socially to "opposing the legal suppression of drug use and the oppression of drug users" (Roe, 2005, p. 243). Harm reduction was initially recognized as a model in the 1980s as an option to abstinence-only centered interventions for adults suffering from addictions. At the time, it was acknowledged that complete abstinence was not a rational or pragmatic goal for those people with an addiction

5. Present Day... • To this day, there is an abundance of research and evidence suggesting that harm reduction advancements significantly lessen the morality and morbidity connected with dangerous health behaviours. An example may include the constant annual decrease of HIV contraction in areas that have implemented the needle-exchange program, in comparison to areas that do not have such a program

6. Statistics • “One of the most definitive studies of needle exchange programmes was carried out in 1997, focusing on 81 cities worldwide. It found that HIV infection rates increased by 5.9 percent per year in the 52 cities without needle exchange programmes, and decreased by 5.8 percent per year in the 29 cities that did provide them” • “According to an Australian government study, investment in needle exchange programmes from 1991 to 2000 averted 25,000 HIV infections and 21,000 hepatitis C infections. A later Australian study examining the impact of needle exchanges in the following decade revealed they had prevented 32,000 HIV infections and almost 100,000 hepatitis C infections”

7. Number of reported AIDS cases in Canada, by year of diagnosis, 1979-2011

8. One example of a harm reduction approach practiced in Vancouver, BC - Insight From January 1 to December 31, 2010, there were: •    312,214 visits to by 12,236 unique individuals•    An average of 587 injections daily•    221 overdose interventions with no fatalities•    3,383 clinical treatment interventions•    26 per cent of participants were women•    17 per cent of participants identified as Aboriginal•    Principle substances reported were heroin (36% of instances), cocaine (32%) and morphine (12%);•    5,268 referrals to other social and health services, the vast majority of them were for detox and addiction treatment;•    458 admissions to Insite detox

9. Key beneficial ethical concerns Research shows harm reduction activities can: • Reduce HIV infection and hepatitis • Reduce overdose deaths and other early deaths among people who use substances • Reduce injection substance use in public places, and reduce the number of used needles in public • Reduce the sharing of needles and other substance use equipment • Educate about safer injecting and reduce injecting frequency • Educate about safer sex and sexual health and increase condom use • Reduce crime and increase employment among people who use substances Increase referrals to treatment programs and health and social services  

10. Ethical Criticisms and issues of harm reduction... Many politicians are not in support of harm reduction approaches because the impacts of addiction on society as a whole • A great deal of politicians (and members of society) do not see harm reduction as “moral”. This causes them to take a “tough on drugs” approach in dealing with all addictions Many people believe that harm reduction programs (such as the needle exchange program) promote intravenous drug use and are a waste money • The goal and message should be complete abstinence from substance  Critics argue that harm reduction strategies teach addicts how to use “properly” • Which again, they suggested is a waste of resources A common concern for many individuals may be that harm reduction entrenches and facilitates addictive behaviour • This idea is rooted in the principle that individuals with an addiction must hit their “rock bottom” before they can discontinue their addictive patterns. These critics believe that harm reduction strategies protect addicts/alcoholics from this “rock bottom” experience 

11. Ethical Criticisms and issues of harm reduction... Another belief among harm reduction critics is that this model encourages addiction amongst individuals who are not addicts • People not in favour of harm reduction would suggest that this strategy sends out the “wrong signals”. From this perspective, harm reduction is promoting the idea that drug users can stay alive and can reduce their exposure to danger; causing addiction to be portrayed as more appealing to non-substance users  Opposing ideas of this strategy might suggest that harm reduction drains resources from treatment services • This author concludes, “Harm reduction interventions are relatively inexpensive and cost effective. They increase social and financial efficiency by interrupting the transmission of infectious disease at a lower cost, rather than waiting to treat complications of advanced illness at a much higher cost”  A final concern worth mentioning is the idea that critics believe harm reduction amplifies addiction disorders, while placing the public safety and health at risk • This idea would assume that the approach utilized by harm reduction becomes a focus and attraction to drug dealers. Further, drug dealers will then compromise the overall welfare and safety of the neighbouring communities

12. Harm Reduction Services: • Impaired driving prevention campaigns: Create awareness of the risks of driving under the influence of alcohol and other legal or illegal substances • Peer support programs: Groups for people who use substances - to improve their quality of life and to address gaps in services • Needle distribution programs: Distribute clean needles and other harm reduction supplies and educate on their safe disposal • Outreach and education: Make contact with people who use substances to encourage safer behaviour • Substitution therapies: Substitute illegal heroin with legal, non-injection methadone or prescription heroin • Supervised consumption facilities: Prevent overdose deaths and other harms by providing a safer, supervised environment for people using substances

13. Ethical GuidelinesClients Best Interest The Canadian Counselling and Psychotherapy Association (2007) describes that, “Counsellors have a primary responsibility to respect the integrity and promote the welfare of their clients. They work collaboratively with clients to devise integrated, individualized counselling plans that offer reasonable promise of success and are consistent with the abilities and circumstances of clients.”

14. Why are these ethical issues important? The ethical issues of best interest of the client and the harm reduction approach has many levels and arguments. Firstly, individuals who are using a harm reduction approach rather than total abstinence may be seen as if they are still in harm by using. Society may not see harm reduction as a effective approach as it allows individuals to still use, they also may argue that this approach is not in the best interest of the client. For the counsellors who support the harm reduction approach, we could argue that this harm reduction approach is actually in the best interest of the client. The reason we could argue this is because although the client may not be totally abstinent, they are reducing/safely using reducing many other negative aspects of using drugs/alcohol. Some clients cannot physically or mentally become abstinent from using, therefore this is the first step by having the client reduce their using or use safely. If the client has already reached out for your helped, they have already taken a step towards recovery. As a counsellor/professional you can help the client reduce/use safely while working with them towards total abstinence.

15. SKILLS AND SENSITIVITES ADDICTION COUNSELLORS MUST POSSESS WHILE UTILIZING THE HARM REDUCTION APPROACH Imperative harm reduction techniques and attitudes which therapists must hold and be sensitive to include… • Accept and respond to improvement A majority of treatment centers require the addict/alcoholic to immediately discontinue their substance(s), and rejects people who are unable to do so. According to Peele (2002), this is the “cherry-picking” of clients; choosing to only work with clients who can maintain complete abstinence, and refusing all others. Peele, “Substance abuse counsellors who wish to work with this large majority need to define intermediate goals and to recognize such positive steps when these occur” • Improvement includes any lessening of harms the person experiences Substance abuse counsellors should look at the client’s improvement in any form. Counsellors should not be too rigid in identifying what is successful for that client. Perfectionism (or abstinence), is not always realistic and successful for all clients at certain periods of their recovery process • Humility (versus perfectionism) is a clinical skill Peele (2002) states, “When people say, ‘I will not tolerate any kind of drinking in therapy, and therapists who do endanger the lives of their clients,’ their own patients must surely have perfect compliance. Not! It's just that they insisted on abstinence, so that any failures were those of their clients, and not their own. While this may assuage therapists' consciences, it is not effective therapy”

16. SKILLS AND SENSITIVITES ADDICTION COUNSELLORS MUST POSSESS WHILE UTILIZING THE HARM REDUCTION APPROACH Anticipate and incorporate continued harms in therapy According to Peele (2002), there are a lot of delusions around the idea that a client should solely depend on their counsellor for any improvements they make. In actuality their improvements entail learning and experiencing the pain of their past mistakes. As substance abuse counsellors, we need to consider, recognize and acknowledge all the year’s addicts and alcohols have spent developing and feeding into their addiction, and that positive changes may take the same time of trial and error to get it just right. This might mean that we should consider continued use may occur while working with clients in achieving their goals while reducing harm to themselves Learning to take care of oneself is a skill, a value, and an attitude Peele (2002) states it perfectly in that, “To say one accepts that human beings are imperfect does not mean that you endorse their imperfection. You want to encourage those you are helping to greater heights and larger successes. But it is the recognition and encouragement of smaller successes that lead to such progress. In particular, helping people to think about how to take care of themselves, even if they continue to drink and take drugs, may be an entirely new attitude for some people. When they first start getting medical care for health problems, or eating well or avoiding infection, or staying out of legal trouble, or getting a place to live, or accumulating money, etc., this new attitude can grow so that it crowds out all problem drug use or drinking”

17. SKILLS AND SENSITIVITES ADDICTION COUNSELLORS MUST POSSESS WHILE UTILIZING THE HARM REDUCTION APPROACH According to the Non Prescription Needle Use Initiative (2007), when working with clients using the harm reduction approach, substance use counsellors need to utilize strategies such as… Offer support that helps people become aware of their substance use and take steps to reduce the harm With a genuine approach, take the time to establish trust Meet people where they are, taking into account readiness to change, education level, resources and self-esteem. This could include reviewing pamphlets and other written information together to explain and answer questions Set the stage for individuals to talk openly and honestly about their substance use. Let them know you accept and care for them Help people with basic resources and life skills to make it less likely they will fall back. As a social worker or counsellor, you are often helping people build skills to handle day-to-day tasks. When people who use drugs try to take positive steps forward but lack basic skills and resources others take for granted, they are in a vulnerable position to slide back into old patterns Support people with skills as fundamental as paying bills, filling out forms, knowing what groceries to buy and doing laundry

18. SKILLS AND SENSITIVITES ADDICTION COUNSELLORS MUST POSSESS WHILE UTILIZING THE HARM REDUCTION APPROACH Recognize that relapse is part of recovery. Relapse is part of recovery – almost nobody changes their behaviour the first time. Many people have a series of ups and downs, just like a person trying to lose weight. People who relapse often feel shame and guilt that can lead to more substance use Tell the person you believe in their ability to make positive changes in their life Work together to create an individual plan for relapse to minimize the harm Use a relapse as an opportunity to ask the person to identify what they have learned from the experience and to plan how to do things differently next time Be supportive at whatever stage of change the person is at Don’t take the individual’s relapse personally Advocate for people’s needs. People using alcohol or other drugs are often not treated as well as others when they seek social or medical supports. As an advocate, you can broker situations and reduce barriers between individuals and formal systems Where needed and possible, accompany individuals to appointments, e.g. meetings with parole officers, lawyers and landlords Your role can be to make sure their questions are asked and to assist them in accessing supports for which they are eligible (e.g. completing forms) Help others understand that people with substance use problems deserve and are entitled to care and services Advocate for systems and changes to policies that may place the people you serve at risk

19. RELEVANT WEBSITES: EDUCATIONAL RESOURCES • Canadian Harm Reduction Network www.canadianharmreduction.com A virtual meeting place for individuals and organizations dedicated to reducing the social, health and economic harms associated with drugs and drug policies. The site hosts forums, provides links to news articles, publications, and links to other web-based resources related to drug use • Canadian Centre on Substance Abuse www.ccsa.ca The Canadian Centre on Substance Abuse provides national leadership and evidence-informed analysis and advice to mobilize collaborative efforts to reduce alcohol and other drug-related harms • City of Vancouver Four Pillars Drug strategy http://vancouver.ca/fourpillars/fs_fourpillars.htm Outline of the four pillars of the City of Vancouver drug strategy: prevention, treatment, harm reduction, and enforcement. The site includes fact sheets for • Burnet Institute Centre for Harm Reduction (Australia) www.chr.asn.au/resources/factsheets Fact sheets based on scientific evidence, current practice and latest research explaining key topics on working with people who use drugs. Intent is to prevent the transmission of HIV/AIDS. Intended for a broad audience, including field workers, public health practitioners, police, journalists, politicians and policy makers • Drug Policy Alliance www.dpf.org Harm-reducing alternatives to current anti-drug strategies • Harm Reduction Coalition www.harmreduction.org Overview of the principles of harm reduction and the need for harm reduction approaches to drug use and drug-related problems. Health information for users, news, policy research, and links to other drug-related websites are included

20. RELEVANT WEBSITES: EDUCATIONAL RESOURCES Harm Reduction Policy Paper http://www.albertahealthservices.ca/Researchers/if-res-policy-harm-reduction-background.pdf This paper was created by Alberta Health Services (formally AADAC) in 2007. The information provided includes principles of harm reduction, harm reductions history/context, examples of harm reduction and evidence proving its effectiveness, key considerations as well as further reading materials British Columbia – Ministry of Health http://www.health.gov.bc.ca/cdms/harmreduction.html This website offers a detailed description of what harm reduction entails. This website also offers further links to additional information regarding harm reduction

21. RELEVANT WEBSITES: HARM REDUCTION IN PRACTICE • Insite, Vancouver Coastal Health • www.vch.ca/sis • Description of North Americas first supervised injection site in Vancouver, BC. News articles and brochures are available to download. Links to research conducted by the British Columbia Centre for Excellence in HIV/AIDS are provided • Ontario Needle Exchange Programs: Best Practice Recommendations • www.ohtn.on.ca/compass/Best_Practices_Report.pdf • Thorough report on best practices for needle exchange programs, with a review of the effectiveness literature to demonstrate evidence superior Points Harm Reduction Program Manual designed for staff and volunteers of Superior Points Harm Reduction Program (Thunder Bay District Health Unit). Applicable for other agencies providing harm reduction services, already running and not yet operational • Toronto Harm Reduction Task Force - Peer Manual, A Guide for Peer Workers and • Agencies • www.canadianharmreduction.com/readmore/ichip_peerManual.pdf • Generic “map”; researched, written, designed and produced by drug users/ex-users for peer workers and agencies delivering services from a harm reduction model. The guide covers a range of topics related to peer work and includes illustrative case scenarios and sample documents • Vancouver area Network of Drug users (VaNDu) • www.vandu.org • VANDU case study reports and other information on supervised injection sites, and evaluation studies • Chicago Recovery Alliance • www.anypositivechange.org • Description of services offered by the Chicago Recovery Alliance to support injection drug users in making positive changes, as defined the user him/herself. Information on vein care, overdose, and hepatitis is available to download

22. RELEVANT WEBSITES: ALBERTA INITIATIVES ON HARM REDUCTION Alberta Harm Reduction Conference www.albertaharmreduction.ca The goal of the annual Alberta Harm Reduction Conference is to raise awareness in Alberta about the application of harm reduction principles amongst service providers who deal with populations vulnerable to hepatitis C and HIV/AIDS and to build capacities within those vulnerable communities. Conference participants typically include professionals from a diversity of sectors (e.g. health care, social work, addictions, corrections, police services, public health) and community members who use harm reduction services (e.g. people who use(d) drugs, current and former sex trade workers, people living with HIV/hepatitis C). An ideal forum to share best practices and experiences related to harm reduction and a variety of areas including drug use, addictions issues, sexual health, sex work, Aboriginal communities, public policy development etc Non-Prescription Needle use (NPNu) Initiative The NPNU Initiative is a multi-sectoral alliance of government, community agencies, and associations that share common vision and action to move harm reduction forward in Alberta, Canada. Since 1995, the NPNU Initiative has evolved to become a shared responsibility between many departments, levels of government, and community agencies. Policy makers meet with field level staff and other stakeholders to identify issues, develop a shared plan of action, and respond to recommendations to reduce the harms associated with injection drug use, particularly as they relate to the transmission of HIV and hepatitis C. A 37-member, multi-sectoral Consortium, a 17-member Steering Committee, seven theme-specific task groups, needle exchange agencies and a Provincial Coordinating Committee on opioid Dependency are the working components of the Initiative

23. Case Illustration Sarah just found she is 2 months pregnant. She is an active alcoholic and drinks on average 5 drinks a day. She has contacted you at the pregnancy support center in regards to being pregnant and the fear that she will not be able to quit drinking but not wanting to harm her unborn child. The two of you meet and Sarah tells you that she will not be able to be completely abstinent from drinking during her pregnancy but does not want to have an FASD child. As a professional you share with Sarah the effects of drinking while pregnant and explore with Sarah her patterns of drinking. The first step you take with Sarah is working with her to help reduce her drinking. 1. As a professional is this in the best interest of your client? 2. What other ways would you work with Sarah regarding this issue? 3. Although it would be in best interest of your client and her child to completely quit drinking, what are the benefits of having Sarah reduce her drinking while pregnant? 4. If your supervisor came to you and said that you are being completely unethical by using a harm reduction approach in this circumstance, how would you argue that what you are doing is truly in the best interest of the client?

24. References Alberta Health Services. (2007). Harm reduction policy background paper. Retrieved from http:// www.albertahealthservices.ca/Researchers/if-res-policy-harm-reduction-background.pdf Averting HIV and Aids. (n. d.). Needle exchange and harm reduction. Retrieved from http://www. avert.org/needle-exchange.htm BC Centre for Disease Control. (2013, March 8). Harm reduction. Retrieved from http://www.bc cdc.ca/prevention/HarmReduction/default.htm British Columbia – Ministry of Health. (n. d.). Harm reduction. Retrieved from http://www.health. gov.bc.ca/cdms/harmreduction.html Canadian Counselling and Psychotherapy Association (2007). Code of ethics. Ottawa, ON: Author. D’Angelo, A. M. (2012, March 7). Harm reduction program benefits many at North America’s only supervised injection site. Canada’s Health Newspaper. Retrieved from http://www.hospital news.com/ harm-reduction-program-benefits-many-at-northamerica%E2%80%99 s-only- supervised-injection-site/ Harm Reduction. (n. d.). A British Columbia community guide. Retrieved from http://www.health. gov.bc.ca/library/publications/year/2005/hrcommunityguide.pdf Leslie, K. M. (2008). Harm reduction: An approach to reducing risky health behaviours in adolescents. Canadian Paediatric Society, 1, 53-56. Non Prescription Needle Use Initiative. (2007). Working with people who use drugs: A harm reduction approach. Public Health Agency of Canada. (2012). At a glance - HIV and AIDS in Canada. Retrieved from http://www.phac-aspc.gc.ca/aids-sida/publication/survreport/2011/dec/index-eng.php